CAQH CORE and Health Level Seven International (HL7) announce a collaboration to address long-standing healthcare industry challenges by accelerating automation and improving interoperability between administrative and clinical systems. This is the first time these two organizations, which conduct complementary work to improve the electronic exchange of data across the healthcare industry, have collaborated on solutions to specific technical and administrative burdens.
“Our collaboration will help move the healthcare industry towards greater automation and streamlined business processes,” said April Todd, senior vice president, CAQH. “We are delighted to work with HL7 to address some of the biggest interoperability issues facing the industry.”
The two organizations will initially collaborate in three areas:
Prior Authorization: Currently, the prior authorization process is a labor intensive, time consuming, and costly administrative burden for providers and payers. It also frustrates patients and, in some cases, delays care. HL7 and CAQH CORE will collaborate to move the industry towards end-to-end automation of the prior authorization process.
Exchange of Medical Documentation: According to the CAQH Index, 84 percent of attachments, or documents that prove medical necessity, are exchanged manually and often contain too much, too little, or the wrong type of information. This delays prior authorizations, hinders the transition to value-based payments, and costs plans and providers time and money. HL7 and CAQH CORE will work to align their respective efforts to support the electronic exchange of clinical information and medical documentation.
Value-Based Payments: The transition to value-based payment models has been slowed by a patchwork of administrative and technical approaches and work-arounds. HL7 and CAQH CORE will work together to address the interoperability challenges causing administrative burden for innovative payment models.
“HL7 and CAQH have made great strides to improve the exchange of information in the healthcare continuum,” said Charles Jaffe, MD, PhD, CEO, HL7 International. “Our collaboration will enable better alignment and accelerate progress toward interoperability between clinical and administrative systems.”
By Shara Cohen, vice president of customer experience, Clinical Effectiveness, Wolters Kluwer, Health.
Hospitals and health systems are under enormous pressure
to provide high quality care in an environment of declining reimbursements and
shifting payment models. With the rise in value-based payments, provider
organizations must increasingly focus on the health and performance metrics
across whole populations.
Shara Cohen
To provide patient-centered care and remain financially
viable, providers need to adopt technologies that expand the reach and
targeting of their care teams and enable them to forge personal connections
with patients. Many provider organizations have been slow to adopt technology
for fear of de-personalizing the patient relationship. Yet technological
solutions designed for people and their specific, pressing needs can be
incredibly effective.
Take Interactive Voice Response calls (IVR), for example.
These automated calls can extend the reach of care teams who need to find out
from patients how they’re progressing in their recovery. Even better, these
calls give patients a chance to check in with caregivers using the most
natural, familiar technology there is: the telephone and the human voice. From
pre-procedure to post-discharge, here are three ways voice technology can
reduce costs while achieving better outcomes:
1. Staying Connected with Patients after Discharge
Discharge is one of the most critical handoffs in healthcare. Traditionally hospitals have employed nurses to make phone calls to recently discharged patients. But what may seem like a simple chat is in fact far more labor intensive. The volume of calls required, and the time needed to connect with patients, establish rapport and elicit critical information has made this an expensive and time-consuming endeavor. IVR calls can reduce the burden on nursing staff while also increasing the level of constructive interaction with patients.
For example, our team worked with a hospital that used two nurses to call as many patients post-discharge as they could. In a one-month period the nurses made 1,932 calls to patients – and of those calls, only 5.2% resulted in a situation that actually required the nurses’ clinical knowledge. The two nurses then started over, this time using IVR. During a same one-month period, the nurses were able to reach out to four times as many patients and connected with 79.8%. The higher rate of connection gave the hospital far more visibility into the actual health status of its discharged patients. It also saved time so nurses could concentrate on personal patient interventions that required their clinical expertise and training.
2. Breaking Down Behavioral Barriers
Voice User Interface (VUI) design is increasingly
utilized to foster emotional connections with patients and help them self-manage
their conditions. As hospitals and providers look to reduce “white coat
syndrome,” and find ways for patients to feel more comfortable sharing
information in a non-judgmental setting, human-centered VUI design can bring a
unique approach to personalization.
For instance, one of our programs reached out to patients newly diagnosed with diabetes. With focus on empathic VUI design, these patients were asked to report on key indicators such as their weight fluctuation, medications, and access to follow-up care. Flagging logic then signaled any instance when a patient may need a live nurse or some other intervention. Surprisingly, these automated calls also elicited sensitive information that may have otherwise not been flagged.
Most enrollees said depression had hindered their ability to manage their condition and 83% also said they had not discussed these issues with a healthcare professional. When given the choice, over half of those respondents opted for additional phone calls that were specifically designed to offer emotional support. Even more, the depression scores of nearly three-quarters of patients decreased over the course of their interactions.
3. Reducing Readmissions
As a last example, patients who engage with IVR phone calls are less likely to be readmitted to the hospital. At one major hospital system, 80% of enrolled patients engaged with calls and they were readmitted less often than those who did not engage. (10.7% 30-day readmission rate vs. 13%.) This result means that voice technology is helping to solve a known and important health quality problem —reducing the rate of unnecessary readmissions—as well as helping hospitals to avoid Medicare penalties. In addition, the decreased readmissions rate frees up beds for new revenue-generating patient admissions.
And the nurse caregivers are now able to work at the top of their license, increasing their job satisfaction as well as their efficiency. In the end, it’s not just caregiver satisfaction and patient outcomes that improve. Patients also appreciate the follow up from these calls, leading to increased patient satisfaction and HCAHP scores.
Ultimately, scaling patient outreach efforts with
interactive voice technology offers a number of benefits for health systems:
from more efficient and effective care management to better patient outcomes at
less cost. That’s a win-win for providers and patients alike.
Regardless of whatever business you operate, the end goal is always customer satisfaction and healthcare is no different. Since healthcare is particularly valuable, it makes sense that the financial reward given to a valuable service should be high and based on a value model.
However, value-based models in healthcare do not have the same outcomes as they do in other businesses.
Value-based payments
Value-based payments have their advantages and disadvantages. For instance, on the one hand, value-based systems effectively liberate physicians from the constraints of fee for service so that they can concentrate on the overall health of their patients. Alternatively, some people say that value-based payment systems impose unneeded extra pressure on providers without necessarily getting the job done.
What is value-based payment in medicine?
Value-based systems reward physicians and healthcare providers with incentive payments for the quality of care given to patients with Medicare. These payment systems are part of a strategy to improve how healthcare is delivered and paid for. The purpose of any value-based system is to:
Improve how patients are given care in hospitals
Improve the overall health of the population
Lower the overall cost of healthcare
Effectively, value-based systems move toward paying doctors and healthcare providers based on the quality of care rather than the quantity of care given. Instead of charging patients based on the number of visits and tests that they order (fee for service payments), today, more hospitals are charging based on the value of the care that they give.
Fee for service payments
Traditionally, healthcare providers are refunded by third-party payers like insurance firms or by the government through Medicare or Medicaid. The amount of money that is paid is set at a going rate that is typically established by the agencies themselves. Since the budgeting of the costs and expenses are based on third party consumers, the system is marred by administrative hiccups, which has led to runaway care costs at the expense of the quality of care given and the patient.
The differences
The difference between fee for service and value-based payments lies in reimbursements and the quality of care provided.
